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13 | On December 18, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:40 AM to conclude a complaint investigation. Initial complaint visit was on 5/1/2024. LPA Calandra was greeted by Ricardo Aban, Executive Director and explained the purpose of the visit.
Regarding the allegation that lack of supervision resulted in resident falling and sustaining multiple fractures, the Department reviewed documents and conducted interviews. Based on document, R1 was a fall risk. Based on interviews, staff were aware that R1 had multiple fall incidents but were not able to provide details on how many times R1 fell, and there is no documentation about any injuries from R1's falls. In addition, some staff were unaware that R1 was a fall risk. On 3/6/2024, R1 fell at 0500 hours,but staff were unaware R1 had fallen until it was reported by R1 at approximately 0900 hours. Furthermore, staff were aware that R1 had fallen multiple times but did not know R1 had sustained fractures.
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| Substantiated | Estimated Days of Completion: |
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13 | On December 18, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:40 AM to conclude a complaint investigation. Initial complaint visit was on 5/1/2024. LPA Calandra was greeted by Ricardo Aban, Executive Director and explained the purpose of the visit.
Regarding the allegation that lack of supervision resulted in injury to resident due to altercation between residents, LPA conducted interviews. Based on interview of Executive Director, LPA Calandra learned that staff were present at the time of the incident and immediately took action including redirection/separation of residents and provided care to resident. In addition, no serious injury that made cause to call for emergency response was noted at time of incident on 4/23/2024.
Regarding the allegation that facility staff did not safeguard resident's personal belongings, LPA Calandra conducted interviews of staff. Per interview of Executive Director, Ricardo Aban, the resident's responsible party asked for R1's personal belongings to be stored securely with facility staff and was safeguarded and accessible to R1 at all times.
The department has investigated the above allegations. The allegations are UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
An exit interivew was conducted. This report was reviewed with Ricardo Aban, Executive Director and a copy of the report left at the facility.
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| Unsubstantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/18/2024
Section Cited
CCR
87465(g) | 1
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7 | 87465(g) Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat....
This requirement was not met as evidenced by: | 1
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7 | Licensee/Administrator to submit to CCLD details on additional training to be conducted on 911 including attendee log, details such as topics covered, and qualifications of professional trainer. Licensee changed policy to conduct hourly checks on residents who are identified as a fall risk. Licensee also conducted a 911 training on 9/5/2024. |
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14 | Based on interviews, R1 fell at the facility at 0500 hours but facility staff did not call 911 until R1’s family arrived at the facility 5-6 hours later. This is an immediate health, safety, or personal rights risk to persons in care.
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Type A
12/19/2024
Section Cited
CCR
87464(f)(1) | 1
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7 | 87464(f)(1) Basic Services: Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidenced by:
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7 | Licensee/Administrator shall increase monitoring of residents who are identified as a fall risk to 30 minutes. Additional training on room checks and identifying to staff which residents are a fall risk will be conducted. Licensee/Administrator to submit plan of dates of training, content, trainer qualifications/contact information, list of attendees. |
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14 | Based on record review and interviews, R1 fell in their bathroom and staff did not know R1 had fallen until four hours later. Per documents review, R1 was a fall risk. In addition based on staff interviewed, staff were to conduct hourly checks on R1 however, due to a lack of supervision, R1 fell and the facility did not know until four hours later. This is an immediate health, safety, or personal rights risk to persons in care.
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